Anesthetic Implications for Patients on Steroids Undergoing Surgery Claire Yang, SRNA Duke Class of 2013

Case Presentation

Steroid-induced Adrenal Insufficiency

Objectives Review physiology of the Hypothalamic Pituitary Axis – specifically glucocorticoid regulation during increased stress as seen in surgery Identify the patient population most susceptible to adrenocortical hypofunction. Recognition of adrenal suppression and secondary adrenal insufficiency Perioperative management of patients treated with glucocorticoids

Hypothalamic-Pituitary-Adrenal (HPA) Axis

Cortisol: Essential for Life Cortisol (synthetic form: hydrocortisone) Required for vascular and bronchial smooth muscle to be responsive to catecholamines Aids in fats, protein, and carbohydrates metabolism  Blood sugar through gluconeogenesis Anti-inflammatory

Cortisol Secretion Highest in the morning (20ug/dL) Lowest around midnight (5ug/dL) Normal daily output: 10-20mg/day General anesthesia and surgery: 150 mg/day

Activate HPA  Cortisol Surgical stress Trauma Sepsis Hypoglycemia Hypothalamic-Pituitary-Adrenal (HPA) Axis in Healthy People Stoelting’s, 5 th ed

Addison’s dx Normal ACTH Destruction of adrenal cortex 1° Adrenal Insufficiency  ACTH Pituitary surgery/irradiation Chronic synthetic glucocorticoid use 2° Adrenal Insufficiency

Biochemical Diagnosis of Adrenal Insufficiency ACTH-stimulation test Withhold exogenous steroids x24 hrs* Baseline cortisol level IV synthetic ACTH 250ug ✓ Cortisol level at 30 and 60 minutes later A cortisol level < 20 μg/dL at any time point shows adrenal insufficiency

Adrenal insufficiency: S/S Fatigue, weakness, anorexia Nausea and vomitting Hypotension Hypovolemia Hyponatremia Hyperkalemia Acute adrenal crisis  circulatory collapse

Rheumatoid arthritis COPD Exacerbation Asthma Flare Crohn’s ds Low Back Pain Common Chronic Conditions Treated with Glucocorticoids Head Trauma Recent Use of Etomidate Trauma Patient Populations Potentially at Risk for HPA axis Suppression

All Kinds of Formulation Oral IV Inhaler Topical ointment/creams Intra-articular injections for arthritis Epidural injections for lumbar disk pain Eye drops Nasal spray

Benefits Adverse Effects Osteoporosis Decreased immune response Steroids-induced diabetes Hypertension Avoid Vascular Collapse Maintain Homeostasis

Adverse Effects of Glucocorticoids Hypertension Glucocorticoid-induced Diabetes Decreased immune response Osteoporosis Peptic ulcer disease Fatty liver

Supra-physiologic Dosing > 7.5mg Prednisone per day or its equivalent Cushingoid appearance Hypothalamic-pituitary-adrenal suppression Adrenal suppression:  cortisol production When discontinued abruptly: risk for Adrenal insufficiency Cleveland Clinic J Med, 78(11),

Various Steroids and Equipotent Doses (Oral or IV)

Adrenal Suppression with Exogenous Steroids Adrenal Suppression secondary to corticosteroid therapy depends on multiple factors: Dose Duration Frequency Time Route of Administration Clinical Relevance Onset: as early as 1 week after starting corticosteroid therapy Recovery: can take from 2 weeks to 6-12 months

Management of Anesthesia for Patients Treated with Glucocorticoids

No specific anesthetic agents and/or technique are recommended in managing patients with or at risk for adrenal insufficiency

Who should receive steroid cover for surgery?

Suppressed HPA Axis Patients receiving > 20mg/day of prednisone for greater than 3 weeks Any patient on glucocorticoids with Cushing’s appearance Intermediate Patients Patients on doses of 5mg/day to 20mg/day Patients have variability in HPA axis suppression Dependent on age, sex, dose, duration of therapy Consider evaluation of HPA axis suppression by way of morning serum cortisol or ACTH stimulation tests Intra-Articular and Spinal Glucocorticoid Injections HPA axis suppression has been reported Factors include dose, interval and number of glucocorticoid injections Suggest testing of HPA axis suppression in patients receiving > 3 injections (Hamrahian, Roman, & Milan, 2012)

Hydrocortisone (Solu-Cortef) Supplementation Local anesthesiaNo supplement Take usual AM dose Minor (inguinal hernia repair) + 25mg IV Moderate (cholecystectomy, total joint, hysterectomy) mg IV taper 1-2 days Major (Cardiac, liver, whipple) mg IV taper 1-2 days Salem et al. Perioperative glucocorticoid coverage. A reassessment 42 years after emergence of a problem. Ann Surg 1994; 219:

Hamrahian, A., Roman, S., & Milan, S. (2012)

Treatment of Acute Adrenal Crisis

Hydrocortisone 100mg IV Hydrocortisone 10mg/hr x 24 hrs Fluid replacement (D5 NS) Glucose replacement and monitoring Arterial line placement/ABG Vasopressor and inotropic support

Conclusion and Further Research Adrenal hormones are essential for life. Too much or too little can be dangerous

Conclusion and Further Research It appears, within the literature, at the very least, patients should receive their steroid regimen leading up to surgery

Conclusion and Further Research Those who miss doses, should be considered at risk Administering supplemental steroids should be considered based on the type and duration of the surgery

Conclusion and Further Research Furthermore, the benefit of administering steroids outweighs the risk or consequences of steroid administration

References Axelrod, L. (2003). Perioperative management of patients treated with glucocorticoids. [Review]. Endocrinol Metab Clin North Am, 32(2), Hamrahian, A., Roman, S., & Milan, S. (2012, August). The Surgical Patient Taking Glucocorticoids. Retrieved from Lansang, M. C., & Hustak, L. K. (2011). Glucocorticoid-induced diabetes and adrenal suppression: how to detect and manage them. [Review]. Cleve Clin J Med, 78(11), doi: /ccjm.78a Pavlaki, A., Magiakou, M., Chrousos, G. (2011). Chapter 13: Adrenal insufficiency. Retrieved from Salem, M., Tainsh, R. E., Jr., Bromberg, J., Loriaux, D. L., & Chernow, B. (1994). Perioperative glucocorticoid coverage. A reassessment 42 years after emergence of a problem. [Review]. Ann Surg, 219(4),

References Wakim, J. H., & Sledge, K. C. (2006). Anesthetic implications for patients receiving exogenous corticosteroids. [Review]. AANA J, 74(2), Welsh, G., Manzull, E., Nieman, L. (2007). The surgical patients taking glucocorticoids. UpToDate. Retrieved from